autogenic drainage.pdf

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32 Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989 Autogenic drainage: a modern approach to physiotherapy in cystic fibrosis M H Schoni MD Alpine Kinderklinik Pro Juventute, CH-7270 Davos Platz, Switzerland Keywords: cystic fibrosis; physiotherapy; autogenic drainage; PEP mask; forced expiration technique Introduction The aim of chest physiotherapy is to prevent respiratory complications and to improve pulmonary function in cases of acute or chronic pulmonary disease. The goals of physical intervention are to maintain normal movement of the chest, to strengthen auxiliary respiratory muscles, to mobilize secretions, to prevent unproductive cough, to maintain or improve exercise tolerance, to learn some breath relieving body positions, and finally to improve self esteem. To reach these goals, several techniques have been developed which can be used according to patients' needs. This paper reviews the approaches to physiotherapy in cystic fibrosis (CF). Historical reports Since 1935 there have been several differing ideas about physical therapy'. The most common breathing exercises used to be pursed-lips breathing, controlled deep breathing to open up poorly ventilated areas, breathing with prolonged expiration and upper chest pressure, and diaphragmatic breathing. Improvement of lung function was reported by Miller2 after 3-month breathing training for patients with chronic airway obstruction. This, however, was challenged by Sinclair3, and later by Becklake et al.4. The mainstay of pulmonary therapy in CF has long been postural drainage with percussion and vibration. However, since postural drainage with percussion represents only one special aspect of a multimodal therapy, its efficacy is unclear. Postural drainage and percussion (clapping) The goal of postural drainage and percussion of the chest is to increase the rate of removal of secretion from a particular segment or lobe of the lung by gravitation. The results are frequently excellent in patients with bronchiectasis. Immediate improvement of maximal expiratory flows and specific airway conductance have been described5'6. However, others have not been able to reproduce these results7. The comparison of chest clapping and postural drainage and emptying a ketchup bottle8 has stimulated researchers and physiotherapists to investigate, clinic- ally and scientifically, the effects of the traditionally applied physical therapy. The opinion that the volume of secretions has to be large enough (> 30 ml/d) to be jarred loose by percussion or vibration has been challenged by Pryor et aL9 who combined a forced expiration technique (FET/huffing) with conventional assisted postural drainage and percussion. Despite the fact that this new forced expiration technique resulted in only a small measurable improvement of lung function (increase of FEV1 of 6%) these authors concluded that the efficiency of postural drainage is improved by using forced expiration. Since postural drainage is known to have some adverse effects on oxygen saturation, and because stopping chest physio- therapy for as little as 3 weeks6 results in a reversible worsening of lung function, other therapies have been evaluated. Forced expiration technique (FET) Apart from regular physical exercise or special breathing exercises, the forced expiratory technique was the first self-performed chest physiotherapy reported to be useful for CF patients, and is based on the concept of the equal pressure point (EPP) theory of Mead et al.'0. It has also been shown that FET was as effective as conventional physiotherapy in inducing cough and mucus clearance9. Support of this tech- nique has also been given by the observation that transpulmonary pressure during FET was significantly less than during coughing, and therefore less airway compression occurred. The main advantage of this technique is that it is easily performed alone by the patient and thus avoids dependence on other individuals for treatment. This technique has, however, been questioned by Rossman" and others6 who found that (i) direct coughing was as effective as any other techniques in the removal of secretions and (ii) that any lung function test failed to show any relief of airway obstruction despite elimination of various amounts of sputum. Vigorous coughing (11 times over 10 min) was comparable to conventional physiotherapy with postural drainage and clapping in terms of the resulting sputum production and in influencing flows at mid or low lung volume in another study'2. From this, it would be reasonable to instruct a patient that vigorous coughing can be used to replace chest physiotherapy when it is impractical to perform the latter. Positive expiratory pressure breathing (PEP) Some investigators have introduced helping devices to support physiotherapy interventions, to improve the loosening of sticky secretions, to increase the volume of removable sputum, to provide self- performed chest physiotherapy and to avoid high pulmonary pressure swings as they occur during coughing. A lightweight vibrator can be used to support percussion and this form of therapy has been shown to be as effective as therapist-administered chest percussion and vibration'3. A randomized study evaluated whether positive expiratory pressure (PEP), applied with a face mask, improved the ketchup bottle method'4. Despite the fact that only minor improvements in sputum amount was observed

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Transcript of autogenic drainage.pdf

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32 Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

Autogenic drainage: a modern approach tophysiotherapy in cystic fibrosis

M H Schoni MD Alpine Kinderklinik Pro Juventute, CH-7270 Davos Platz, Switzerland

Keywords: cystic fibrosis; physiotherapy; autogenic drainage; PEP mask; forced expiration technique

IntroductionThe aim of chest physiotherapy is to preventrespiratory complications and to improve pulmonaryfunction in cases of acute or chronic pulmonarydisease. The goals of physical intervention areto maintain normal movement of the chest, tostrengthen auxiliary respiratory muscles, to mobilizesecretions, to prevent unproductive cough, to maintainor improve exercise tolerance, to learn some breathrelieving body positions, and finally to improve selfesteem. To reach these goals, several techniques havebeen developed which can be used according topatients' needs. This paper reviews the approachesto physiotherapy in cystic fibrosis (CF).

Historical reportsSince 1935 there have been several differing ideasabout physical therapy'. The most common breathingexercises used to be pursed-lips breathing, controlleddeep breathing to open up poorly ventilated areas,breathing with prolonged expiration and upper chestpressure, and diaphragmatic breathing. Improvementof lung function was reported by Miller2 after3-month breathing training for patients with chronicairway obstruction. This, however, was challenged bySinclair3, and later by Becklake et al.4. The mainstayof pulmonary therapy in CF has long been posturaldrainage with percussion and vibration. However,since postural drainage with percussion representsonly one special aspect of a multimodal therapy, itsefficacy is unclear.

Postural drainage and percussion (clapping)The goal of postural drainage and percussion of thechest is to increase the rate of removal of secretionfrom a particular segment or lobe of the lung bygravitation. The results are frequently excellent inpatients with bronchiectasis. Immediate improvementof maximal expiratory flows and specific airwayconductance have been described5'6. However, othershave not been able to reproduce these results7. Thecomparison of chest clapping and postural drainageand emptying a ketchup bottle8 has stimulatedresearchers and physiotherapists to investigate, clinic-ally and scientifically, the effects ofthe traditionallyapplied physical therapy. The opinion that the volumeof secretions has to be large enough (> 30 ml/d) to bejarred loose by percussion or vibration has beenchallenged by Pryor et aL9 who combined a forcedexpiration technique (FET/huffing) with conventionalassisted postural drainage and percussion. Despite thefact that this new forced expiration technique resultedin only a small measurable improvement of lungfunction (increase of FEV1 of 6%) these authors

concluded that the efficiency of postural drainage isimproved by using forced expiration. Since posturaldrainage is known to have some adverse effects onoxygen saturation, and because stopping chest physio-therapy for as little as 3 weeks6 results in a reversibleworsening oflung function, other therapies have beenevaluated.

Forced expiration technique (FET)Apart from regular physical exercise or specialbreathing exercises, the forced expiratory techniquewas the first self-performed chest physiotherapyreported to be useful for CF patients, and is based onthe concept of the equal pressure point (EPP) theoryof Mead et al.'0. It has also been shown that FET wasas effective as conventional physiotherapy in inducingcough and mucus clearance9. Support of this tech-nique has also been given by the observation thattranspulmonary pressure during FET was significantlyless than during coughing, and therefore less airwaycompression occurred. The main advantage of thistechnique is that it is easily performed alone bythe patient and thus avoids dependence on otherindividuals for treatment. This technique has,however, been questioned by Rossman" and others6who found that (i) direct coughing was as effective asany other techniques in the removal of secretions and(ii) that any lung function test failed to show any reliefof airway obstruction despite elimination of variousamounts ofsputum. Vigorous coughing (11 times over10 min) was comparable to conventional physiotherapywith postural drainage and clapping in terms of theresulting sputum production and in influencing flowsat mid or low lung volume in another study'2. Fromthis, it would be reasonable to instruct a patientthat vigorous coughing can be used to replace chestphysiotherapy when it is impractical to perform thelatter.

Positive expiratory pressure breathing (PEP)Some investigators have introduced helping devicesto support physiotherapy interventions, to improvethe loosening of sticky secretions, to increase thevolume of removable sputum, to provide self-performed chest physiotherapy and to avoid highpulmonary pressure swings as they occur duringcoughing. A lightweight vibrator can be used tosupport percussion and this form oftherapy has beenshown to be as effective as therapist-administeredchest percussion and vibration'3. A randomizedstudy evaluated whether positive expiratory pressure(PEP), applied with a face mask, improved theketchup bottle method'4. Despite the fact that onlyminor improvements in sputum amount was observed

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Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989 33

when the PEP method was compared to posturaldrainage, FET, clapping and directed coughing, anddespite the absence of any short-term improvementin lung function, the PEP mask was said to be themost acceptable, subjectively. It has been argued thatPEP mask breathing affects the peripheral airwaysand collateral air channels, whereas coughing andFET were only effective in airways where dynamiccompression occurs. One month of PEP treatment,however, was not superior to conventional clappingphysiotherapy15 whereas 18 months of forcedexpiration through PEP, a slightly modified PEPtechnique with high expiratory pressures, increasedsputum yield in the range of 20%, increasedexpiratory flow rates, decreased hyperinflation andlowered airway instability16. The results of compar-able studies over short axid long periods are given inTable 1.

ExercisesThe need to have effective physiotherapy has beendemonstrated by the fact that continual physicaltherapy improves well being and the life of the CFpatients. Besides active treatment it has beenrecognized that sports at school and physical exercisesmay substitute for chest physiotherapy in a minorityof patients. Although one study has shown that7 weeks of supervised swimming training can improvelung function'7, in another study, 3 months exercisetraining at home did not improve lung function orexercise tolerance and resulted in poor compliance18.Favourable results of controlled sporting activitiescompared to physiotherapy were, however, reportedby Blomquist'9, Edlund20 and Stanghelle2122. Asupplement of the International Journal of SportsMedicine23 has highlighted the benefits and pitfallsof exercise and training in CF patients. Otherreports24 suggest that active physical treatment -such as PEP mask breathing - and exercise havedifferent immediate effects, with PEP mask breathingbeing superior to submaximal exercise in terms ofsputum production. For. older patients, ergometerexercise training at home improved the sense ofwell-being and had a positive effect in clearing sputum inan adjunct to routine chest physiotherapy25.

Autogenic drainage (AD)In the search for an improved self-performed chestphysiotherapy to provide independence to the patientand the most effective lung clearance of secretions,Chevaillier introduced a novel technique which wasbased mainly on precise observation of patients.Mobilization of mucus was constantly observed inchildren during sleep when one could hear the mucusmove. Furthermore daily observations of childrenshowed that during breathing exercises, during anti-crisis techniques (positions which are taken duringacute asthmatic attacks), during playing andlaughing and during FEV, manoeuvres, mucusmoved better than most of the time during posturaldrainage, pursed lip breathing, vibration andclapping. Based on these observations, Chevaillierintroduced autogenic drainage (AD) which hedescribed as a series of principles. In his description26,based on a paper by Alexander-7 and later again ina paper by Kraemer et aL28, the principle of reachingthe highest possible airflow in different generationsof bronchi by controlled breathing was put intopractice by a three phase breathing exercise. The aim

was to (a) unstick the peripheral mucus by breathingat low lung volumes, (b) collect the mucus in themiddle airways by breathing at tidal volume level andfinally (c) evacuate the secretions from the centralairways by breathing at higher lung volumes. At thebeginning of this breathing technique, inspirationshould be slowly through the nose to guaranteeoptimal moistening and heating of the inspired air;this partly prevents coughing. At the end of aninspiration a short stop of breathing with an openglottis is performed. Expiration is done withoutpursed lips breathing through the open mouth andopen glottis; the latter has to be learned and practised.Whether the glottis is kept open or closed can beverified by gasping without making a sound. By thisbreathing manoeuvre compression and bronchialobstruction are probably avoided.The first phase of unsticking secretions is then

started by a directed increased inspiration followedby deep expiration. By concomitantly lowering midtidal volume below FRC level, the range of closingvolume is automatically reached and secretions fromperipheral lung regions are mobilized by compressionof peripheral alveolar ducts. Mid respiratory tidalvolume is lowered in the range of normal expiratoryreserve volume (ERV). The end of inhalation isfollowed by a short breathing stop with open glottisto ensure equal filling of all the lung segments,including the obstructed ones, by collateral filling.During the next exhalation the alveolar pressurewill be the same in most lung parts, with minorparadoxical airflow. The second phase of collectingmucus in the larger bronchi is achieved by deepeninginspiration and expiration. Tidal volume breathingis then changed gradually from expiratory reservevolume into the inspiratory reserve volume (IRV)range to mobilize secretions from the apical parts ofthe lungs as well. The velocity of flow must becontrolled to avoid high flow peaks which result inspasm of the collapsible segments at the equalpressure point (EPP). The longer the expirationtime, the greater the distance the secretions aretransported. In the third and last phase the patientincreases flow starting from a level at about themiddle of his inspiratory reserve capacity (IRC) andby a small burst of coughing the mucus is finallybrought out. At the end of this phase self controlof flow is essential to avoid unproductive forcedcoughing.All the three phases are depicted in Figure 1 which

has been drawn according to the published data ofKraemer28. Several points havelto be consideredwhen learning this technique: first, it can only belearned by the help ofa trained person; secondly, thepatient is in an upright sitting position, undergoesrelaxation and concentration, performs diaphragmaticbreathing and tries to avoid paradoxical movementsofthe chest and coughing; thirdly, when learning thistechnique the patient is guided by tactile and auditiveassistance of the teacher, which he gradually takesover and adds his proprioceptive sensations fordetecting moving secretions; and finally, sessions of30-45 min twice a day are necessary.Based on the theory that, with autogenic drainage,

higher flows of a longer duration can be achievedwhen performing partially forced expirations startingfrom various volumes smaller than the total lungcapacity (TLC), we registered flow volume curves fromCF patients during autogenic drainage, from which

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Table 1. Summary ofpapers dealing with physiotherapy listed according to year as they appeared since 1979

Duration DurationiAuthor n ofsession of trial Techniques Results

16 98-127 min

10 lh

Rossman" 6 40 min 5 days

. ~~ ~ ~ ~ ~ ~ ~ I.

DeCesarel 10 n.i. 1 day

Desmond6 10 n-i. 6 weeks.~~~~~~~~~~~~~~~~~~~~~~~~~~~

10 30 min

24 30 min

De Boeck2 9 25 min

4 dayq A: PD, coughing, selfpercussion, shaking by physioB- PD, FLT, coughing, selfpercuissionC: B+percussion by physio

7 weeks Swimming

A: spontneous coughB: PD; C: PD+percussionD: PD, deep breathingpercussion by physioE: directed coughingCleariig 99 m Tc aerosol

4 days

1 day

2 days

14 20-35 min 4 days

86 30 min 3 months

12 15 min 1 day

16 n.i.

10 30 min

16 n.i.

74 n.i.

VerboonM 8 1.5 h 4 days

4 days

4 days

On B treatment timedecreased, sputum weightincreased, FEVy increased6%B vs C not significantAfter course lung functionimproved; 10 weeks laterreturned to preswimming levelAll better than AE was as good as B, C or DNo additional benefit fromPD or physio help comparedto directed coughing

Krpton 81 m scan after Improvement of ventilationPD pereussion and vibration seen only in patients withby physiotherapist severe disease3w PD, percussion, vibration When off therapy significantat home; 3w without physio decrease of FVC (3%),

FEF25-75 (20%), FEV1 (10%)Significant long-term effect,no immediate effect

A: Resting in upright(control) During C, D more clearingB: Directed coughing than during A, B. Wet sputumC: FET morewith B, C, D than A,D: FET+PD FET and FET+PD superior99 m Tc clearance to direct coughingLung function at 30 min FEF 25 decreased, sGawand 2 h after physio increased of 10-20%. Direct(PD, percusion, coughing) cinema demonstration of-

bronchial narrowingLung function at 1 h after Static lung volumes not25 min physio session vs affected. FEF 50 and FEF 25coughing alone increased 14% resp. 22% with

coughing alone 18%, 25%resp. after physio

A:PD, FET, clapping, cough Sputum amodnt B, C> D, AB: PD+PEP, FET, cough lung function: no effectC: PEP, FET, cough after A FVC decreased 6.6%D: Pursed lip, cough Saturation: decreased A>B,PEP 15-30 cm H0 C, D; incr B, C, Drandomized, cross over C subjectively best acceptedexercise No effect on lung functionat home and on exercise tolerance,

compliance at home poorPEP, lung function before During PEP FRC increasedimmediate after and 15 min Decrease of washout volumelater lung clearance index and

trapped gas. No effect onTLC, TV, RV

A: PD without percussion Sputum weight A 57, B 52 gB: PD, FET self percussion B: FEV1 -improved (no values)randomized4 double coughs/3 min sitting4 FET/3 min sitting4PET/3 min in PD

".

4 days PET- PET+percussion

FET+PD2 years FET

FETFET+PD

Sputum production, amountradioaerosol clearancebetter after FET, FET+PDthan after cough aloneNo effect on FVC, FEV1PEFR on the 5% significancelevelDecrease of lung function inthe range of the naturalcourse of lung functiondeteriorationNo differences in FEV, FVC,PEFR; more sputum on

PET+PI)

continued

Pryor9

Zach"7

Sutton33

Zapletal7

Falk24

Holzer'8

Groth39

Webber34

Parker35

Rogers36

Van derLaag37

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Table 1 continued

Duration DurationAuthor n of session of trial Techniques Results

Tyrrell"5 15 30 min

Webber40 12 n.i.

Webber4" 18 n.i.

Oberwaldner16 20 20-90 min

Blomquist19 11 30 min

Hardy3l

Edlund20

7 20 min

10 50 min

Stanghelle2" 8 3-9 hper week

Stanghelle22 8 100 minper week

Schlemper29 8 30 min

Falk24

Salh25

12 15 min

16 15 min5 times/week

McIlwaine30 18 n.i.

1 month Conventional physiovs PEP

3 days

3 days

FET vs FET+PEP

A: FET+PDB: FET+PEP+PDC: FET+PEP sitting

18 months Forced expiration throughPEP

12 months 6 months physicalexercises6 months physicalexercises+FET

1 day Infants mean age 3.1 monthsPD, percussion vibration

12 weeks Swimming

5 years

8 weeks

2 days

2 days

2 months

4 on training, regularphysical exercise, 4 didno trainingDaily trampoline exercise

Autogenic drainage (AD)vs PEPPEP vs bicycle exercise

Bicycle ergometry athome

2 months 1: PD+percussion2: PEP+huffing3: ADcross over randomized

No differences inlung function afterone monthSignificant improvementwith FET+PD in FEV1,FVC, PEFR, FEF50, nochange in TLC, RV,DLCOSputum in A, B> CA vs B not significantPEP has no additionalpositive effectIncreased yield of sputum(20%). Increasedexpiration flow rates,decreased hyperinflation,decreased airwayinstabilityImprovement of Po2, smallchanges in lung functionduring physical exercise

After physio decreasedcompliance, decreased work ofbreathing and power ofbreathingImproved clinicalstatus, improved exercisetolerance, lung function notchangedThose who trained improvedlung function and peak 02uptakeNo changes in lung function

More sputum on AD 16.3 gthan on PEP 5.8 g (means)Sputum weight duringPEP higher thanduring exercise,no differences inlung function12 had peak work capacitypeak minute ventilation andminute oxygen consumptionimproved. Sputum yieldimproved in 6No changes in lung function12 produced more sputumon AD. Clinical scores thesame in each group

PD, postural drainage;AD, autogenic drainage;PEP, positive expiratory pressure;

FET, forced expiration technique;n.i., not indicated;FVC, forced vital capacity;FEV1, forced expiratory volume in one second;FEF 25,50,75, forced expiratory flow at 25%, 50%, 75% of vital capacity;FEF 25-75, forced expiratory flow between FEF 25% and 75%;PEFR, peak expiratory flow rate;TLC, total lung capacity;TGV, thoracic gas volume;RV, residual volume;sGaw, specific airway conductance

Abbreviations:

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36 Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

NOMAU PHASE: 1 2 3

RV

kl F I_ _ _ I . , v

Figure 1. Phases ofautogenic drainage shown on a spirogramofa normal person Phase 1: unstick, phase 2: collect, phase3: evacuate. (Vt=tidal volume, ERV=expiratory reservevolume, RV=reserve volume, FRC=functional residualcapacity, IRV= inspiratory reserve voume;IRV+ Vt+ERV=vital capacity)

Flow (V)l/sec

Volius (V)

Figure 2. Forced flow-volume curve (fat line) and partial flow-volume curves (small lines as they are produced in AD) froma patient doing autogenic drainage; explanation see text

a representative experiment is shown in Figure 2.During forced expiration, (thick line) compressionoccurs at low lung volumes, whereas, during AD,higher flow transients with the same low lungvolumes are achieved without bronchial collapse.Thus, it seems that moving secretions is made easierin the peripheral parts of the lung.However, parts of this technique have been

challenged by German physiotherapists and clinicanswho stated that breathing in the ERV range wasseldom observed in their patients due to difficulties tolower mid tidal volume level. Therefore, they simplifiedthe procedure so that the patient begins by moving hismid tidal volume up and down by deepening breathsand comfortably adapts the process to his individualneed without undue force or effort. After a breatharrest of about 2-3 s at the end ofevery inspiration, apassive, relaxed but rather fast expiration to normalexpiratory level follows, succeeded by an activelyperformed expiration supported by expiratory inter-costal muscles and thus driving down exhalation tolow ERV. Therefore, this 'German' technique uses acombination of diaphragmatic and rib-cage breathing.In patients with easily collapsible airways, a

proximal expiratory stenosis such as pursed lips ornose breathing is recommended. Using this modified

technique preliminary results have been presented29,showing that the mean sputum amount with AD was16.3±4 g and with PEP mask breathing it was5.8±2.6 g, (n=8 CFI's, age 4-17 years, immediateeffect after one session withAD or PEP). In this samereport it is claimed that trapped gas was significantlyreduced. However, these data have never beenpublished in a peer reviewed journal, and results are,therefore, to be interpreted with caution. Autogenicdrainage has also been compared with PEP, PD andconventional physiotherapy by a cross-over design bythe Vancouver Children's Hospital group30. Theseauthors reported that after a two month period oftherapy several advantages ofAD or PEP over conven-tional therapy occurred in patients with hyperreactiveairways with more sputum produced with AD. Theseresults agree with our own experiences. In a twoweek's controlled inpatient study no statisticallysignificant improvement of lung function occurred,but sputum production decreased and transcutaneousoxygen saturation improved.

ConclusionsSeveral techni-ques are available today for effectivephysiotherapy in CF patients. No single technique isbetter than the others, so an individual adjustmentofa specific technique has to be determined for everypatient. General rules cannot be given but guidelinescan be suggested to adjust the techniques to the needsofthe patient. Age, severity ofthe disease, concomitantpathology, familiarity with the technique, family back-ground, social situation, intelligence, selfesteem andacceptance have to be considered when the physio-therapy regimen is considered for a patient. A multi-disciplinary approach is needed, with the views ofphysicians, nurses, physiotherapists, sport therapists,parents and friends being taken into account whendevising the physical therapy for each patient. Thebest technique' for any patient is the one which hefeels most comfortable with and is able to continue,which produces the largest amount of sputum, andwhich maintains acceptable health according to thestage of disease. It is also known that the enthusiasmof the physiotherapist, physician or teacher affects thelevel of benefit received from the treatment. In thisway, every effort we direct towards the individual needsof the patient is rewarded by his or her well being.

Acknowledgment: The author thanks Mrs Rita Kieselmann,Munich, for assistance in teaching autogenic drainage in ourclinic.

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